Healthcare Provider Details

I. General information

NPI: 1134753676
Provider Name (Legal Business Name): ALISSA AUDREY DYKSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 11/16/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 WOODCLIFF CIR SE
GRAND RAPIDS MI
49506-3155
US

IV. Provider business mailing address

3426 DANA DR
HAMILTON MI
49419-8571
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 616-834-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: